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The Role of Non-Medical Exemptions in the Current Epidemiology of Measles in the U.S.

The Role of Non-Medical Exemptions in the Current Epidemiology of Measles in the U.S. Preeta K. Kutty MD, MPH Division of Viral Disease National Center for Immunizations and Respiratory Diseases 43 rd National Immunization Conference March 30, 2009. Overview.

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The Role of Non-Medical Exemptions in the Current Epidemiology of Measles in the U.S.

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  1. The Role of Non-Medical Exemptions in the Current Epidemiology of Measles in the U.S. Preeta K. Kutty MD, MPH Division of Viral Disease National Center for Immunizations and Respiratory Diseases 43rd National Immunization Conference March 30, 2009

  2. Overview • History of Immunization Laws • Impact of Non-Medical Exemptions • Measles Epidemiology, 2008 • Challenges • Future Directions

  3. History of U. S. Immunization Laws • 1809- State of Massachusetts requires population to be vaccinated against smallpox • 1905- Supreme court upholds rights of states to pass compulsory vaccination law (Jacobson v. Massachusetts, 197 U.S. 1 (1905)) • 1922 – Supreme Court upholds law requiring vaccination for school entry (Zucht v. King) • 1960-1970’s- school immunization laws used to enhance measles elimination efforts Jackson CL. Public Health Report 1969; 84, (9): 787-795 Orenstein WA, Hinman AR. Vaccine 1999; 17: S19-24

  4. U. S. School Immunization Laws • Are legal requirements that children have received vaccinations as a condition of participation in school • Are all state laws • Vary markedly by state • Are specific for grades and vaccines • Cover public and private schools • May not cover home-schooled children Orenstein WA, Hinman AR. Vaccine 1999; 17: S19-24 National Advisory Vaccine Advisory Committee, 1998:1-5

  5. Effect of School Immunization Laws • Incentive for parents to vaccinate their children to protect the public health • System/safety net for immunization • Extremely effective in achieving very high immunization coverage in school populations • Reducing or eliminating vaccine preventable disease in these populations Orenstein WA, Hinman AR. Vaccine 1999; 17: S19-24

  6. Measles Epidemiology, U.S., 1962- 2008* 1963 Vaccine Licensed 1st Dose Recommendation 1989 2nd Dose Recommendation 2000 Elimination Declared School Immunization laws Measles Cases 1989-91 Resurgence Year *Provisional data reported to NCIRD through 12/31/08

  7. U. S. School Law Exemptions • 1961: First philosophical exemption law was introduced in California as an exemption to polio vaccine • Early 1970’s: Universal implementation of state laws offering medical exemptions based on religion grounds§ • Schools have access to all children, but not all children can be vaccinated • Exemptions allow school participation (which) is legally required for those unable to be vaccinated • Exemptions serve as an “escape valve” for school laws §Evers DB. JONA’s Healthcare Law, Ethics, and regulation. 200;2 (2)

  8. Types of Exemptions • Medical • Child on chemotherapy (temporary) • Child with immune deficiency (permanent) • Religious • Philosophical (Personal Belief) • Vaccination in-progress (temporary)

  9. Types of Exemptions to Schools Laws No. of States* Medical 50 Religious 48§ Personal or 20 Philosophical *http://www.ncsl.org/programs/health/SchoolExempLawsChart.htm §Except Mississippi and West Virginia

  10. Philosophical Exemptions Are Associated with More Exemptors Salmon DA et al. Am J Public Health 2005; 95 (3): 436-440

  11. Impact of Exemptions • Colorado, U.S.: Exemptors were 22 times more likely to have had measles than vaccinated children • Excess risk of measles among exemptors greatest among children ages 3-10 yrs (RR: 62.0; 95% CI: 39.0-98.6) • Incidence of measles among vaccinated children aged 3-10 yrs was significantly associated with the frequency of exemptors in the county • U.S.: From 1985 through 1992 exemptors in all States were 35 times more likely to contract measles than nonexempt children • Netherlands: 224 times (95% CI: 148-460) more likely to acquire measles than vaccinated • Feikin DR et al, JAMA 2000; 284:3145-3150 Salmon DA et al. JAMA. 1999; 282: 47-53 van Den Hof et al, J Inf Dis, 2002; 186: 1483-1486

  12. Measles Epidemiology, U. S., 2008 • 140 cases from 19 states and DC • 127 cases in U.S. residents • 116 (91%) cases unvaccinated or unknown vaccination status • 98 (85%) were vaccine eligible • 67 (68%) were Personal Belief Exemptors (PBEs)

  13. Ratio of Indigenously Acquired toImported Cases, U.S., 2001- 2008* Ratio Cases * Provisional data reported to NCIRD through 12/31/08

  14. U.S. Residents with Measles, January-December 2008, by Age N = 127 80% cases < 20 years

  15. Percent of Cases Aged 5-19 Years Claiming Personal Belief Exemptions (PBE), 2001- 2008* Cases Percent * Provisional data reported to NCIRD through 12/31/08

  16. Large Measles Outbreaks in Pockets of Unvaccinated School-aged Children • Indiana (2005): 34 cases • 3 hospitalizations • 28 school-aged children • Only 1 was vaccinated • 20 home-schooled (none were vaccinated) • Public Health cost: $167,685 • San Diego (2008): 12 cases • 4 children were exposed in the pediatrician's office (3 were <12 months) • 7 school-aged children • None were vaccinated (all were PBE*) • Public Health cost : ~ $177,000 • Washington State (2008): 19 cases • 16 school-aged children • 11 home-schooled • None were vaccinated (all were PBE) • Public Health cost : $140,000 *PBE: Personal Belief Exemptors

  17. MMR Vaccine Coverage *http://www.cdc.gov/vaccines/stats-surv/nis/data/tables_0708.htm £http://www2.cdc.gov/nip/schoolsurv/nationalDetail8.asp?v=Measles&y=2008 §Courtesy of Indiana State Department of Health

  18. Exemption Rates may VaryConsiderably within a State http://www.doh.wa.gov/cfh/Immunize/documents/k12exempconty08.pdf

  19. Reasons Parents Choose Not to Immunize their Children: Indiana, 2005 Kennedy AM, Gust DA. Pub Health Reports. 2008;123: 126-134

  20. Summary • School immunization laws played a crucial role in measles and rubella elimination in the U.S. • Measles Epidemiology, 2008: • Largest number of cases reported in over a decade • Characterized by: • High proportion of cases among unvaccinated U.S. residents • High proportion of cases in school-aged children whose parents claimed exemptions • Many of these children were homeschooled

  21. Ongoing Challenges • The U.S. remains at risk for measles importations and thereby more measles outbreaks. • Maintain high 2-dose vaccination coverage rates • Possibility for large measles outbreaks exists • Monitor the impact of vaccine exemption, and understand reasons for vaccine exemptions • Effect of school immunization laws, measurement of exemptor rates, and identify communities at risk

  22. Future Directions • Monitor trends in the U.S. - Measles and other vaccine preventable diseases - PBE - Vaccine preventable diseases among PBE • Determine knowledge, attitudes and beliefs of exempt and non-exemptor population • Home schooled children may be an important population to study

  23. Acknowledgements State and Local Health partners Division of Viral Diseases - Kathleen Gallagher - William Bellini - Susan Redd - Paul Rota - Albert Barskey - Jenny Rota - Amy Parker - Mark Papania - Charles LeBaron - Jane Seward - Huong McLean - Greg Armstrong - Greg Wallace Disclaimer The findings and conclusions are those of the authors and do not necessarily represent the view of the Centers for Disease Control and Prevention

  24. 1967 Thank you pkutty@cdc.gov

  25. Additional Slides

  26. MMR Vaccine Recommendations • Children: • Routine: • 1st dose between 12-15 months • 2nd dose between 4- 6 years of age • Traveling abroad: • 6-11 months – 1 dose • ≥12 months – 2 doses ≥28 days apart • Adults: Absent proof of immunity • 2 Doses: health care workers, international travelers, university students • 1 dose: others

  27. Nonmedical Exemptions for States With Religious Exemptions and With Personal Belief Exemptions -1991 - 2004 Only Religious Exemptions Permitted Personal Belief Exemptions Permitted Exemption Rate Exemption Rate Omer , Pan, Halsey et al., JAMA, 2006

  28. Key Differences Between Parents of Exempt and Non-exempt Children

  29. Measles Cases Reported to CDC, 2008 (N= 140) Grant County, WA Outbreak N=19 Missaukee County, MI Outbreak, N=4 Milwaukee County, WI Outbreak, N=6 New York City, NY N=27 San Diego, CA Outbreak N=12 (CA =11, HI =1) Du Page Co, I L Outbreak N=31 Pima County, AZ Outbreak N=14

  30. Reported Measles Cases, U.S. 1997-2008*, by Importation Status *Provisional data through December 31, 2008

  31. Measles Importations, U.S. 2008 140 cases 24 importations D5 D4 D4 D4 D5

  32. Personal Belief Exemptions in Kindergarteners, San Diego County, 2008 * * Courtesy of D. Sugerman et al.

  33. Europe: Incidence of Reported Measles Cases by Age-group, 2006-2007 Muscat M et al. lancet 373: 383-389

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